Medicare Coverage

Frequently Asked Questions about Medicare Part D Coverage for the Omnipod® System

In addition to coverage under the medical device and pharmacy benefit insurance plans, the Omnipod® Insulin Management System may also be covered by Medicare as a Part D (prescription) benefit. This means that people with diabetes of all ages can make the insulin management system choice that is right for them.

As we work with Part D carriers to add the Omnipod® System to their formulary, we’ve compiled answers to frequently asked questions that should help you understand how Medicare Part D coverage could impact you.

How long did it take you to secure Medicare coverage and why did it take so long?

This has been a persistent effort since Insulet Corporation launched the Omnipod® Insulin Management System. The Centers for Medicare and Medicaid Services (CMS) communicated they had not comfortably assigned the Omnipod® System to a benefit category due to the unique design and physical attributes of the product. CMS has since issued guidance clarifying that products such as the Omnipod® System may be covered under the Medicare Part D (prescription) program. We are thrilled to now have the Omnipod® System formally covered by CMS as a Part D benefit.

What ultimately convinced CMS to provide coverage? Why did they change their mind?

It was less CMS changing their mind and more them clarifying that products such as the Omnipod® System fit into this criteria. CMS maintains that the Omnipod® System is not coverable as a DME benefit and therefore must be covered as a Part D benefit.

Does this Medicare coverage cover those living with insulin-dependent Type 2 diabetes?

We are assuming the Omnipod® System coverage criteria will be consistent with the coverage criteria outlined in Medicare’s Insulin Infusion Pump National Coverage decision which does not make any distinction between those individuals living with T1 or T2 diabetes. While we believe there are opportunities to deliver the significant benefits of the Omnipod® System to the type 2 user base as we move forward, we are initially mainly focused on the T1D community for this coverage.

When will I be covered under Medicare Part D?

This decision enables your Part D carrier to add the Omnipod® System to their covered formulary list. Insulet Account Executives are now working with Part D carriers to ensure this occurs, and it is a top priority for us in 2018. This process takes time for the carrier to implement, and our expectation is that a majority of the coverage will be in place by early 2019. In the meantime our Medicare Access team may help you work with your Part D carrier to secure a formulary exception. Please feel free to connect with our Medicare Access team at 877-939-4384 to explore this process.

How wilI I know when my plan will cover the Omnipod® System?

Insulet will communicate updates to our progress as we work with Part D carriers to add the Omnipod® System to their formulary. Again, we expect this process to take place over the course of 2018, however we can work with you and your carrier to understand your current coverage via the formulary exception process. If you are a current Podder™, just click here to provide your insurance information online or reach out to our Medicare Access team at 877-939-4384 so we can help you initiate the formulary exception process.

How long could it take for my pharmacy to add the Omnipod® System to their formulary?

If the Omnipod® System is not on formulary for your plan today, we can assist you with the exception process. Once submitted, it will take about a week to know if the exception is approved. If not, we can pursue an appeal. In the meantime, we will also be working with your carrier directly to get the Omnipod® System put on the formulary for all of the carrier's members. It is difficult to predict how long it will take to get the Omnipod® System on formulary for your carrier - our expectation is that the process will take place over the course of 2018. Therefore the exception and appeal process is a good option if you want coverage sooner.

How do I find a Part D Medicare Plan that covers the Omnipod® System?

CMS’s decision to cover the Omnipod® System under the Medicare Part D program enables Insulet Corporation to begin contract negotiations with Medicare Part D carriers. Until these contract negotiations take place, the Omnipod® System is covered, but will not be listed as a covered product on the CMS Website. The good news is that both the Pod and Personal Diabetes Manager are available via the Part D formulary exception process. Please feel free to connect with our Medicare Access team at 877-939-4384 to begin the approval process.

How do I find a pharmacy that carries the Omnipod® System?

We currently have a number of pharmacies that are dispensing the Omnipod® System. Please call our Medicare Access team at 877-939-4384 to explore your pharmacy benefits and to learn what your Part D carrier's in-network pharmacy alternatives are.

How much will the Omnipod® System cost me?

The cost is dependent upon your Part D plan formulary benefits. We can begin a benefits investigation with you to determine what your cost will be. Please call our Medicare Access team at 877-939-4384 to begin exploring this.

How do I get started on the Omnipod® System?

Please call our Medicare Access team at 877-939-4384 and we can help you get started via the Part D formulary exception process.

What does my Medicare plan require me to do to get started on the Omnipod® System?

This will be dependent upon your Part D benefits. Please call our Medicare Access team at 877-939-4384 and we can work with you to begin the approval process.